Address: Level 36, Menara Bangkok Bank, 105, Jalan Ampang, 50450 Kuala Lumpur.
Address: Xxxxx 00, Xxxxxx Xxxxxxx Bank, 000, Xxxxx Xxxxxx, 00000 Xxxxx Xxxxxx.
Toll Free: 0-000-000-000 Tel.: 00-0000 0000 Fax: 00-0000 0000 E-mail: xxxx@xxxxxx.xxx.xx Website: xxx.xxxxxxxxxxxx.xxx.xx
Postcode | ||||||||||||||||||||||||||||||||||
CONTRACTORS ALL RISKS INSURANCE PROPOSAL FORM
Berjaya Sompo Insurance Berhad (62605-U) (BSIB) is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia. | |
IMPORTANT NOTICE | |
Non-Consumer Insurance Contract Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade, business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure for Non-Consumer Insurance Contract shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the questions in this proposal form, you are required to disclose any other matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this proposal form is inaccurate or has changed. | |
PLEASE USE BLOCK LETTERS AND CROSS (X) IN APPROPRIATE BOX | |
DETAILS OF PROPOSER | |
Name of Proposer (in full) : | |
Address (Postal): | |
Business Registration: | ST Registration No : |
Business, Trade or Occupation : | Email : |
Telephone No. (Office) : | Fax No : |
PARTICULARS OF THE RISK TO BE INSURED | |
1. Title of contract (If project consists of several sections. specify section(s) to be insured) : | |
2. Location of erection site Country/Province/distric : City,Town,Village : | |
3. Principal Name(s) : Address(es) : | |
4. Main Contractor Name(s) : Address(es) : | |
5. Subcontrator Name(s) : Address(es) : | |
6. Consulting engineer Name(s) : Address(es) : | |
7. Description of contract work(please give detailed technical information) a) Dimension (length,height,depth,spans,number of floors) b) Foundation (method,level of deepest excavation) c) Construction method d) Construction materials | |
8. Is the contractor experienced in the type of work or construction method ? Yes No | |
(CAR/PF092018) 1
9. Period of insurance Commencement of work Duration of construction Months Date of completion Maintenance period Months | ||
10. Work to be carried out by subcontractors : | ||
11. Special risk • Fire, explosion ? Yes No • Flood, Inundation ? Yes No • Landslide,storm ,cyclone ? Yes No • Blasting work ? Yes No • Other risks? • Volcanism, tsunami ? Yes No • Have earthquakes been observed in this ? Yes No • If so, please state intensity : Magnitude • Is the design of the structure to be insured based on regulation regarding earthquake - resistant structures? Yes No • Is the design standard higher than that stipulated in the relevant regulations ? Yes No | ||
12. Work to be carried out subcontractors : | ||
Please also give answers to Nos. 16 to 21 as far as information obtainable: | ||
13. Is there any aggravated risk of : Fire : Yes No Explosion : Yes No *if so, give details : | ||
14. Ground water level : | ||
15. Nearest river,lake,sea,etc : Name : Distance from site : Level : : Low water : Mean water Highest level recorded : mean level of site : | ||
16. Meteorological conditions : Rainy seasons from : to Max. rainfall(mm) : Per hour : Per day : Per Month: Max. wind velocity : Storm frequency Low Medium High | ||
17. Are extra charges for overtime,nightwork,work on public holidays to be included ? Yes No Limit of indemnity | ||
18. Is third party liability to be included ? Yes No Has the contractor concluded a separate policy for TPL ? Yes No Limit of indemnity | ||
19. Details of existing buildings and surrounding property possible affected by the contract work, such as by excavating, underpinning, pilling, vibration, ground water lowering, etc. | ||
20. Are existing building and / or structures on or adjacent to the site, owned by or held in car custody or control of the contractor(s) or the principal, to be insured against loss or damage arising out of or in connection with the contract work ? Yes No Limit of indemnity Exact description of these buildings/ structures | ||
21. Plese state here under the amounts you wish to insure or where applicable the limits of indemnity required (cf. Policy wording, section I, Memo 1 and section II) : Currency : | ||
Items to be insured | Sums to be insured (state below separately ) | |
1. Contract work ( permanent and temporary work,inluding all materials to be incorporated herein) | ||
1.1. Contract Price | ||
Section 1- Material Damage | 1.2. Materials or items supplied by the principal(s) | |
2. Construction plant and equipment | ||
3. Construction machinery (please attach list showing replacement values of new items) | ||
4. Clearance of debris (insured only up to the amount indicated ) | ||
Total sum to be insured under section I: | ||
Special risk to be isured | Limit of indemnity | |
Earthquake, volcanism, tsunami | ||
Storm,cyclone,flood,inundation, landslide | ||
Section II – Third Party Liability | Insured | Limit of indemnity |
Bodily injury - any one person | ||
Bodily injury – total | ||
Property Damage | ||
Total limit to be applied under section II: | ||
1. Limit of indemnity in respect of each and every loss or damage and or/series of losses or damage arising out of any one event. 2. Limit of indemnity in respect of any one accidents or series of accidents arising out of one event. | ||
PAYMENT METHOD | |
Total Premium Paid: RM Please select payment method. | |
Cash | |
JomPay | For payment via JomPay, please provide proof of payment. |
Visa MasterCard | Card No. Expiry Date - - - m m / y y |
Cardholder’s Name: | |
Date: | Cardholder’s Signature: |
SERVICE TAX (ST) - ST will be imposed on the applicable portion of the premiums due and payable. | |
PRIVACY NOTICE | |
The personal information including your personal, policy and financial details ("Personal Data") provided by and collected from you may be used and processed by us and our Group Companies1 (within or outside Malaysia) in order for us to provide our services and to operate and manage our function as an insurance company. By signing on this proposal form, you consent to the use and processing of your Personal Data for the purposes as stated in our Privacy Notice. If you represent a body corporate, you have procured the necessary consent for our use and processing of the Personal Data provided by you for the purposes as stated in our Privacy Notice. Please refer to the Privacy Notice for details of your Personal Data privacy rights and our rights of disclosure, which is also available at our website at xxx.xxxxxxxxxxxx.xxx.xx. | |
OPTION TO SUBSCRIBE TO CROSS-SELLING ACTIVITIES | |
You can extend your consent for us to use your Personal Data for cross-selling purposes within/with our Group Companies or our strategic business partners or selected third parties, by selecting: Yes No Take note that you can always choose to opt out of the cross-selling activities as described above (including marketing campaigns by any of our Group Companies) at any time by contacting BSIB at the contact number stated above. Note: 1Group Companies refer to Sompo Holdings Group and Berjaya Group, of which BSIB is also an affiliate. | |
DECLARATION BY PROPOSER | |
I/We declare and warrant that the answers/information provided in this proposal form are true and correct and I/We have not withheld any information or made any misrepresentation likely to affect the acceptance of this proposal and declaration which I/We agree shall be the basis of the contract between myself/ourselves and the Company. I/We shall undertake to notify the Company when there is any subsequent change to the information provided in this proposal form. A copy of the product disclosure sheet (“PDS”) is available at our website xxx.xxxxxxxxxxxx.xxx.xx. Please make sure that you have read and understood the contents of the PDS before purchasing the product. | |
Date | Proposer’s Signature: |
(If the Proposer is a company, authorised signature(s) and chop) | |
FOR AGENT / OFFICE USE | |
Cover Note / Policy No.: | |
Intermediary: | |
Account No.: | |
Remarks: | |